Thomas 2017

Chapter 32
Nutritional Management for Gestational

Diabetes
Alyce M. Thomas1 and Maria Duarte-Gardea2
1
St. Joseph’s Regional Medical Center, Paterson, NJ, United States, 2The University of Texas at El Paso, El Paso, TX, United States
I INTRODUCTION dietitians, diabetes educators, nurses, social workers, and

other professionals, works in collaboration with the common
Gestational diabetes mellitus (GDM) is diabetes diagnosed goal of normoglycemia from diagnosis to postpartum.
in the second or third trimester of pregnancy that is not The benefits of lifestyle modifications go beyond the
clearly either type 1 diabetes (T1DM) or type 2 diabetes immediate postpartum period. It may represent an oppor-
(T2DM) [1]. This is how the American Diabetes Association tunity for the registered dietitian and other health care
(ADA) defines GDM in its 2016 Standards of Medical Care providers to impact lifestyle patterns aimed toward estab-
and it represents a shift in the previous definition. Prior to lishing future habits that will benefit the woman and her
2016, GDM was defined for many years as carbohydrate family.
intolerance of variable degree with onset or first recognition
during pregnancy and included all women regardless of
whether the condition may have predated the pregnancy.
II PREVALENCE
Now, according to the ADA, diabetes diagnosed in the first Almost 4 million babies were born in the United States in
trimester is considered undiagnosed T2DM and the treatment 2014 [5]. Although the true prevalence of GDM is unknown,
protocol is the same as for women with T2DM. it is estimated to affect 1 14% of pregnancies in the United
However, other organizations have not adopted this States annually [6]. In a study using the Pregnancy Risk
definition. The World Health Organization (WHO) Assessment Monitoring System, the prevalence was 9.2%
defines GDM as hyperglycemia that is first recognized [6], which could mean the number of pregnancies affected
during pregnancy [2]. GDM is defined by the American by GDM is greater than 350,000 per year. This variation in
College of Obstetricians and Gynecologists (ACOG) as a the prevalence depends on the population studied and the
condition in women who have carbohydrate intolerance diagnostic tests used [7]. In populations with a higher preva-
with onset or recognition during pregnancy [3]. lence of obesity and T2DM, the prevalence of GDM is also
GDM is associated with complications during and after higher [8,9]. This includes Native Americans, Asians,
pregnancy. The woman is at risk of developing GDM in Hispanics, and African American women [10].
subsequent pregnancies and/or T2DM in the future. A cohort study in Colorado that examined the trends
Exposure to maternal hyperglycemia in utero conveys a risk in GDM prevalence among women with diverse ethnic
for obesity and T2DM in the offspring. The key to preven- backgrounds reported an increase from 1.7% to 3.1%
tion or decreasing the risk of complications is to achieve among non-Hispanic whites; from 2.8% to 5.4% in
and maintain optimal glycemic control during the preg- Hispanics, and from 2.9% to 5.4% in African Americans
nancy. The management of GDM includes medical nutrition [11]. A similar trend has been reported for Canadian
therapy (MNT), physical activity, and, if indicated, pharma- aboriginal populations. The prevalence in the inland com-
cological therapy [4]. An interdisciplinary health care team, munities was twice as high as in the coastal communities
which includes endocrinologists, obstetricians, registered (18.0% vs 9.3%, p 5 0.002) [12].
Nutrition in the Prevention and Treatment of Disease. DOI: http://dx.doi.org/10.1016/B978-0-12-802928-2.00032-1

© 2017 Elsevier Inc. All rights reserved. 709
710 PART | E Diabetes Mellitus
TABLE 32.1 Risk Factors for Testing for Diabetes in TABLE 32.2 Maternal and Fetal Complications
Pregnant Women at Their Initial Prenatal Visit Associated With GDM
BMI $ 25 kg/m2 or $ 23 kg/m2 in Asian Americans and with Maternal Fetal
additional risk factors:
G Physical inactivity
G Hypertension G Macrosomia
G First-degree relative with diabetes
G Preeclampsia G Neonatal hypoglycemia
G High-risk race/ethnicity (e.g., African American, Latino,
G Premature delivery G Neonatal hypocalcemia
Native American, Asian American, Pacific Islander) G Cesarean delivery G Hyperbilirubinemia
G Previous delivery of infant whose birth weight .9 lb or
G GDM in subsequent G Polycythemia
previously diagnosed with GDM pregnanciesa
G Hypertension ($140/90 mm Hg on therapy for hypertension)
G Type 2 diabetesa G Respiratory distress syndrome
G HDL-cholesterol level ,35 mg/dL (0.90 mmol/L) and/or
G Cardiovascular diseasea G Stillbirth
triglyceride level .250 mg/dL (2.82 mmol/L) G Metabolic syndromea G Shoulder dystocia
G Polycystic ovary syndrome
a
Postpregnancy complications.
G A1C $ 5.7%
G Other clinical conditions associated with insulin resistance Source: From E.A. Reece, The fetal and maternal consequences of
gestational diabetes mellitus, J. Matern. Fetal Neonate Med. 23 (2010)
(e.g., severe obesity, acanthosis nigricans) 199 203; T.L. Setji, A.J. Brown, M.N. Feinglos, Gestational diabetes
G History of cardiovascular disease
mellitus, Clin. Diabet. 23 (2005) 17 24.
Source: From American Diabetes Association, Standards of Medical

Care—2016. Classification and diagnosis of diabetes, Diabetes Care 39
(Suppl. 1) (2016) S13 S22.
complication associated with GDM and occurs in approxi-
mately 20% of pregnancies in undiagnosed or untreated
III RISK FACTORS GDM [13]. Pedersen hypothesized that maternal hyper-
glycemia results in fetal hyperinsulinemia, lipogenesis,
Risk factors associated with GDM also vary among orga- glycogen, and protein synthesis and subsequent macroso-
nizations. Women were previously categorized as being at mia [14]. In a prospective study that included 115
low, average, or high risk for developing GDM. Low-risk untreated women with borderline GDM by the broader
women were not universally screened for GDM because it criteria of Carpenter and Coustan, the untreated borderline
was not considered cost-effective since they represented GDM group had increased rates of macrosomia (28.7% vs
only 10% of the pregnant population. However, according 13.7%, p , 0.001) and cesarean delivery (29.6% vs
to the ACOG, if traditional historical factors are used 20.2%, p50.02) when compared with normoglycemic
(family or personal history of diabetes, previous adverse controls [15].
pregnancy outcome, glycosuria, and obesity) to identify The effect of complications that develop during preg-
GDM, approximately 50% of women with GDM will be nancy may extend beyond delivery. Women with a his-
missed [3]. ADA identifies women at risk for developing tory of GDM are at increased risk of developing the
GDM in Table 32.1. condition in a subsequent pregnancy or T2DM within 10
years. Her infant is at a higher risk of developing obesity
and T2DM later in life.
IV COMPLICATIONS ASSOCIATED WITH
GDM
Although complications associated with GDM are gener-
V SCREENING AND DIAGNOSIS
ally not as severe when compared to pregnancies with Currently, there is no gold standard for the screening or
preexisting diabetes, perinatal morbidity and even mortal- diagnosis of GDM. This inconsistency is the result of
ity may occur with uncontrolled glycemic levels the lack of data that shows adverse outcomes at various
(Table 32.2). Maternal risks associated with gestational levels of hyperglycemia. O’Sullivan and Mahan estab-
diabetes include hypertension, and increased risk of oper- lished the first diagnostic testing for GDM using a
ative and preterm deliveries. In the infant, complications 3-hour oral glucose tolerance test (OGTT) and whole
include macrosomia, neonatal hypoglycemia, neonatal blood [16]. The National Diabetes Data Group (NDDG)
hypocalcemia, neonatal hyperbilirubinemia, and polycy- proposed using plasma blood glucose and defined GDM
themia. Shoulder dystocia, clavicular fracture, brachial as two or more values higher than the thresholds [17].
palsy, and respiratory distress syndrome are associated Carpenter and Coustan proposed using diagnostic
with GDM more so than in infants born to women with criteria which was lower than those of the NDDG [18].
normoglycemia. Macrosomia, which is defined as a birth This diagnostic criteria also used a two-step approach,
weight greater than 4000 g or 4500 g, is the most common with a 50-g, 1-hour glucose challenge test to screen for
Nutritional Management for Gestational Diabetes Chapter | 32 711
diabetes as the first step. Depending on the results of the VI WEIGHT GAIN IN PREGNANCY
screening (usually .135 mg/dL or 7.5 mmol/L), the
100-g, 3-hour OGTT was performed to diagnose GDM. The current weight gain guidelines from the Institute of
This two-step process of screening and diagnosing GDM Medicine are based on women’s prepregnancy BMI.
is still widely used by many obstetricians. Table 32.4 shows the guidelines for total weight gain for
In 2008, a large multinational study of approximately each BMI category and the weekly weight gain for the
23,000 pregnant women, known as HAPO (Hyperglycemia second and third trimesters [22]. Women should be
and Adverse Pregnancy Outcomes), demonstrated adverse advised to gain according to their BMI category.
perinatal outcomes (infant birth weight greater than the Inadequate weight gain is associated with low birth
90th percentile, cord-blood serum C-peptide, primary weight and small-for-gestational-age infants. Excessive
cesarean section, and neonatal hypoglycemia) at levels that weight gain may lead to macrosomia in the infant, cesar-
were considered normal in pregnancy [19]. Based on the ean delivery, and postpartum weight retention. A prenatal
HAPO data, the International Association of Diabetes and weight gain grid can be used to monitor and evaluate the
Pregnancy Study Groups (IADPSG) proposed new cutoffs amount of weight gain. (See Table 32.5 for an example of
for the diagnostic criteria for GDM [20]. These criteria a prenatal weight gain grid for normal weight women.)
which use the 75-g, 2-hour one-step approach and have
been adopted by the ADA are not universally accepted VII MONITORING IN PREGNANCY
(see Box 32.1). In 2013, the National Institutes of Health’s
Consensus Panel on Diagnosing GDM recommended the Monitoring during GDM provides the woman and her
continuation of the two-step approach because of the lack health care team with the necessary tools to assist her
of evidence which showed the 2-hour OGTT improved with diabetes management. These tools include self
perinatal outcomes [21]. The two-step approach is blood glucose monitoring, ketone monitoring, and glyco-
supported by the ACOG. (See Table 32.3 for the diagnostic sylated hemoglobin (A1C).
criteria of various organizations).
A Blood Glucose Monitoring
The use of self-monitoring blood glucose (SMBG) allows
the medical team to objectively evaluate and, if necessary,
adjust the meal plan or medication. The ADA and ACOG
BOX 32.1 Oral Glucose Tolerance Test recommend that women with GDM monitor their blood
glucose levels four times daily—fasting and after meals
One-Step Approach Two-Step Approach [3,4]. However, the timing of postmeal monitoring has
Oral Glucose Challenge been debated for many years. According to the ACOG
Test (GCT) Practice Bulletin on GDM, no research has demonstrated
G 50-g glucose solution
given at any time of the superiority of either 1- or 2-hour postmeal testing [3].
day Other studies using continuous glucose monitoring
G If results ,135 or (CGM) to determine the peak glucose elevation in preg-
140 mg/dL 1 h later,
administer 3-h OGTT nant woman showed that the peak time was 60 90 min-
3 days later utes from the beginning of a meal [23 25]. Whether
Oral Glucose Challenge Test Oral Glucose Challenge monitoring is performed 1 or 2 hours after eating, it
(OGTT) Test (OGTT)
G 3 days before—normal G 3 days before—nor- should be from the beginning, and not the end, of the
carbohydrate load of mal carbohydrate meal. The frequency of monitoring may be reduced from
at least 150 g load of at least 150 g daily to every third or fourth day once control of blood
G fast at least 8 h before G fast at least 8 h before
test test glucose is established. The target blood glucose levels in

G 75-g glucose solution G 100-g glucose solu- pregnancy are found in Table 32.6.
given tion given
G blood drawn at fast- G blood drawn at fast-
ing, and 1 and 2 h ing, and 1, 2, and 3 h

G during test—no eating, G during test—no eat-
B Urinary Ketone Testing in GDM
smoking, drinking ing, smoking, drinking
(except water), or walk- (except water), or
While blood glucose monitoring is generally recommended
ing (remain seated) walking (remain in the management of GDM, ketone testing is not.
G diagnosis made if one seated) Pregnancy is considered a ketogenic state and ketones may
value is abnormal G diagnosis made if two
values are abnormal be found in the urine in the nondiabetic pregnant woman.
However, the presence of ketones may suggest starvation
ketosis as the result of inadequate energy intake. One early
TABLE 32.3 Diagnostic Criteria for GDM for Various Organizations
Organization Glucose Challenge Fasting Blood 1-Hour Blood 2-Hour Blood 3-Hour Blood
Test (50 g) Glucose Glucose Glucose Glucose
National Diabetes 105 mg/dL 190 mg/dL 165 mg/dL 145 mg/dL
Data Groupa (5.8 mmol/L) (10.5 mmol/L) (9.2 mmol/L) (8.0 mmol/L)
ACOGa , 135 or 140 mg/dL $ 95 mg/dL $ 180 mg/dL $ 155 mg/dL $ 140 mg/dL
(5.3 mmol/L) (10.0 mmol/L) (8.6 mmol/L) (7.8 mmol/L)
IADSPG, ADAa,b $ 92 mg/dL $ 180 mg/dL $ 153 mg/dL
(5.1 mmol/L) (10.0 mmol/L) (8.5 mmol/L)
WHOb 92 125 mg/dL .180 mg/dL 153 199 mg/dL
(5.1 6.9 mmol/L) ($10.0 mmol/L) (8.5 11.0 mmol/L)
a
100 g, 3-hour OGTT.
b
2 75 g, 1-hour OGTT.
ACOG, American College of Obstetricians and Gynecologists; ADA, American Diabetes Association; IADPSG, International Association of Diabetes and
Pregnancy Study Groups; WHO, World Health Organization.
TABLE 32.4 Institute of Medicine Weight Gain in Pregnancy Guidelines
Prepregnancy BMI Recommended Weight Gain Rate of Gain/Week Recommended Total Weight
(2nd and 3rd trimesters) Gain (Twin Gestation)
Underweight (,18.6) 28 40 lb (12.7 18.2 kg) 11/2 lb (0.7 kg)
Normal weight (18.6 24.9) 25 35 lb (11.2 15.9 kg) 1 lb (0.5 kg) 37 54 lb (16.8 24.4 kg)
Overweight (25.0 29.9) 15 25 lb (6.8 11.3 kg) 2/3 lb (0.3 kg) 31 50 lb (14.1 22.7 kg)
Obese ( . 30.0) 11 20 lb (4.5 9.0 kg) Individualize 1/2 lb (0.25 kg) 25 42 lb (11.3 19.1 kg)
Source: From National Academy of Sciences, Weight Gain During Pregnancy: Reexamining the Guidelines, National Academy Press, Washington, DC, 2009.
study had indicated a possible link between ketonemia and the continuous fetal draw of glucose from the mother,
decreased intelligence in the offspring [26]. Neither the maintaining consistency of times and amounts of food
ADA nor the ACOG include ketone testing for women eaten are important to avoid hypoglycemia. During preg-
with GDM in the Standards of Medical Care or Practice nancy, the distribution of energy and carbohydrate intake
Bulletin on GDM, respectively [3,4]. However, women should be individualized and based on the woman’s food
with GDM should avoid controlling their blood glucose preferences and plasma glucose responses. Plasma glu-
levels by consuming insufficient calories. cose monitoring and daily food records provide valuable
information for insulin and meal plan adjustments [27].
C Hemoglobin A1C The estimated energy requirements (EERs) during the
first trimester are the same as those for a nonpregnant
The target of A1C in pregnant women with preexisting woman with an additional 340 calories during the second
diabetes is 6 6.5% (42 49 mmol/mol) [4]. There is and 452 calories during the third trimesters [28]:
currently no recommendation to monitor the A1C in
women with GDM. 1st trimester: adult EER for women (no calorie
increase);
2nd trimester: adult EER for women 1 160 kcal
VIII NUTRITION MANAGEMENT (8 kcal*/week 3 20 week) 1 180 kcal**; and
MNT for GDM primarily involves a carbohydrate- 3rd trimester: adult EER for women 1 272 kcal
controlled meal plan that promotes optimal nutrition for (8 kcal*/week 3 34 week)1180 kcal**.
maternal and fetal health with adequate energy for appro- *8 kcal/week5estimated change in the total energy
priate gestational weight gain, achievement and mainte- expenditure in pregnancy.
nance of normoglycemia, and absence of ketosis. Due to **1805mean energy deposition during pregnancy.
TABLE 32.5 Prenatal Weight Gain Grid
Source: Downloaded from N.C. Department of Health and Human Services Women’s and Children’s Health Section. http://www.nutritionnc.com/wic/pdf/
NormalWeightSingletonGestationWeightGainChart.pdf.
TABLE 32.6 Target Plasma Glucose in Gestational Diabetes Pregnancy
Time American Diabetes Association and American CDAPP International Diabetes

College of Obstetricians and Gynecologists Federation
Fasting #95 mg/dL (5.3 mmol/L) # 60 89 mg/dL (3.3 5.0 mmol/L) ,90 mg/dL (5.5 mmol/L)
1 hour #130 mg/dL (7.2 mmol/L) 100 120 mg/dL (5.6 6.7 mmol/L) ,140 mg/dL (7.7 mmol/L)
2 hours #120 mg/dL (6.7 mmol/L) ,120 mg/dL (6.6 mmol/L)
CDAPP, California Diabetes and Pregnancy Sweet Success.

Source: From International Diabetes Federation IDF GDM Model of Care Implementation Protocol Guidelines for Healthcare Professionals. http://www.idf.
org/sites/default/files/attachments/GDM-model-of-care-2015.pdf (accessed 01.06.16).
The amount and distribution of carbohydrate should levels of women who followed the low CHO diet were
be based on clinical outcome measures including hunger, significantly lower after breakfast (102 6 16 vs
plasma glucose levels, weight gain, and ketone levels. To 94 6 11 mg/dL), lunch (105 6 12 vs 99 6 9 mg/dL), and
ensure provision of glucose to the fetal brain (approxi- dinner (112 6 16 vs 103 6 13 mg/dL) (p , 0.05). Women
mately 33 g/day) a minimum amount of 175 g/day of car- following the high carbohydrate diet also experienced a
bohydrates should be provided [28]. Carbohydrate should significant decrease in glycemia after lunch (106 6 15 vs
be distributed throughout the day in three small- to 96 6 7 mg/dL) and dinner (107 6 12 vs 97 6 7 mg/dL)
moderate-sized meals and two to four snacks. An evening (p , 0.05); however, their glucose concentration after
snack may be needed to prevent accelerated ketosis over- breakfast did not change. It was concluded that high and
night. Carbohydrate is generally less well tolerated at low carbohydrate diets are effective and safe; however, a
breakfast than at other meals [29]. low-carbohydrate diet should be recommended to women
who experience high glucose levels after breakfast [33].
A Carbohydrates B Dietary Fat

Carbohydrate is the primary nutrient affecting postprandial Fat content in the diet of a pregnant woman usually ranges
glucose levels, and postprandial blood glucose concentra- from 30% to 40% of total calories; however, large amounts
tion is the one that has the most important role in macroso- of fat beyond total caloric needs should be avoided to pre-
mia [30]. The conventional diet approach to GDM vent excessive weight gain, which can result in further
advocates for carbohydrate restriction, resulting in higher insulin resistance. The acceptable macronutrient distribu-
fat content, which is also a substrate for fetal fat deposit and tion range of fat is 20 35% of total energy, the same as
associated with maternal insulin resistance. Consequently, for nonpregnant women [28]. The impact of increasing
there is no consensus about the optimal GDM diet. The tra- polyunsaturated fatty acid intake on blood glucose, lipid
ditional approach to diet therapy in GDM has been carbohy- metabolism, and pregnancy outcomes of women with
drate restriction (30 40% energy from total calories), with GDM was assessed in a randomized controlled study that
the goal of reducing postprandial glucose, in order to miti- included 84 pregnant Chinese women. Women were ran-
gate glucose-mediated fetal macrosomia [3,31]. domly divided into two groups: an intervention group (pre-
However, in a randomized controlled trial of 152 scribed a daily oil-rich diet of 45 50 g sunflower oil,
women with GDM that were assigned to follow a diet low 50 54% carbohydrates, 31 35% fat) and a control group
(40%) or high (55%) of total energy from carbohydrates (low-oil diet of 20 g sunflower oil, 55 60% carbohy-
(CHO), no difference was found in insulin use between drates, 25 30% fat). In both the intervention and the
the groups. In addition, no differences were found in the control groups, fasting blood glucose, 2-hour postprandial
obstetric and perinatal outcomes between the treatment plasma glucose, and the insulin resistance index decreased
groups (e.g., ketonuria, hypertension, cesarean sections) significantly post-intervention (p , 0.05); the lipid
[32]. The blood glucose levels of women with GDM were changes and pregnancy outcomes did not differ signifi-
significantly lower after lunch and dinner when they were cantly between the two groups (p . 0.05). It was con-
exposed to a high-carbohydrate diet. In another study that cluded that an appropriate increase in polyunsaturated
compared two different carbohydrate levels in women fatty acid intake benefits pregnant women with GDM as
with GDM, 30 Caucasian women were randomly assigned well as fetuses, as long as the diet therapy follows basic
to follow either a low- or a high-carbohydrate diet (45% recommendations and total energy intake is strictly con-
and 65% of energy, respectively). The blood glucose trolled [34].
In a randomized controlled study by Lauszus et al., in the omega-3 fatty acids plus vitamin E group were sig-
the effects of a high monounsaturated fatty acid (MUFA) nificantly different from the changes in these indicators in
diet compared to recommended high-carbohydrate diet the placebo group. Overall, it was demonstrated that
were studied in 27 women with GDM. After randomiza- omega-3 fatty acids and vitamin E cosupplementation in
tion women received either a high-carbohydrate diet GDM women had beneficial effects not only on glucose
(H-CHO): 50% carbohydrate, 20% protein, 30% fat [11% homeostasis parameters but also in serum triglycerides,
MUFA]) or a high-MUFA diet (H-MUFA): 46% carbohy- VLDL-cholesterol, and HDL-cholesterol concentrations.
drate, 16% protein, 37% fat [22% MUFA]) from the 33rd Supplementation of omega-3 fatty acids and vitamin E
gestational week of pregnancy. Outcome measures were did not have an influence on total cholesterol and LDL-
24-hour ambulatory blood pressure, blood lipids, glyce- cholesterol levels [37].
mic control, and insulin sensitivity estimated by an intra-
venous glucose tolerance test. Results indicated that the
24-hour diastolic blood pressure increased more in
C Protein
the H-CHO group than in the H-MUFA group (p , 0.04). The diet of well-nourished women in the preconception
The H-MUFA diet had no advantage to the H-CHO diet period and throughout most of pregnancy has a significant
in ameliorating the decline of insulin sensitivity in the effect on birth weight, and protein is the macronutrient
third term of pregnancy in GDM; however, the favorable with the greatest influence. Cuco et al. [38] demonstrated
effect on blood pressure by the MUFA diet might be used that in a protein and fat model, a 1-g increase in maternal
as a possible nonmedication treatment [35]. protein intake during preconception and in the 10th, 26th,
Furthermore, the effects of omega-3 fatty acid supple- and 38th weeks of pregnancy led to a significant increase
mentation were studied in a randomized, double-blind, in birth weight of 7.8 11.4 g. Conversely, high intakes of
placebo-controlled study among 56 women with GDM. protein and fat during pregnancy may impair development
Subjects were randomly assigned to receive either of the fetal pancreatic beta-cells and lead to insulin defi-
1000 mg omega-3 fatty acid supplements containing ciency in the offspring [39]. In a case control study of
180 mg eicosapentaenoic acid and 120 mg docosahexanoic 2341 women with singleton pregnancies, three different
acid (n 5 28) or placebo (n 5 28) for 6 weeks. Fasting levels of protein in the diet were associated with birth
blood samples were taken at baseline and after 6 weeks of weight. Birth weight was 77 g lower (p 5 0.021) in the
intervention. A significant difference in changes in low-protein group and 71 g lower (p 5 0.009) in the high-
serum insulin levels (from baseline: 21.5 6 7.5 vs protein group compared with the intermediate-protein
13.5 6 8.5 µIU/mL, p 5 0.02) and homeostasis model group. Birth weight increased with protein levels up to
assessment estimated insulin resistance (HOMA-IR) 69.5 g/day and declined with higher protein intake. A
(20.4 6 2.1 vs 11.1 6 2.4, p 5 0.02) was found when high average prenatal protein consumption resulted in a
comparing the two groups. In addition, a significant reduc- significant depression of birth weight; in fact, a protein
tion in serum high-sensitivity C-reactive protein (hs-CRP) intake of more than 84 g/day on average is more detri-
levels was seen after omega-3 fatty acid supplementation mental than a low protein intake. It appears that moderate
when compared with the placebo (2236.3 6 1541.9 vs protein intake is optimal during pregnancy [40].
898.6 6 2292.7 ng/mL, p 5 0.03). The authors concluded The effect of soy intake on metabolic status of women
that omega-3 fatty acid supplementation in GDM women with GDM was studied in a randomized clinical trial among
had beneficial effects on insulin resistance. Plasma glu- 68 women with GDM. Women were randomly assigned to
cose, HOMA for beta-cells, quantitative insulin sensitivity receive either a control diet containing 0.8 g/kg protein
check index, and lipid profiles were not affected [36]. (70% animal and 30% plant proteins) (n534) or a soy diet
The combination of omega-3 fatty acid supplementa- containing the same amount of protein with 35% animal
tion with vitamin E was tested on glucose homeostasis protein, 35% soy protein, and 30% other plant proteins
parameters and lipid concentrations among women with (n534) for 6 weeks. Compared with soy protein
GDM not taking oral hypoglycemic agents. In a random- consumption, the control group significantly increased fast-
ized controlled trial, women were allocated to take either ing plasma glucose (11.4 6 11.6 vs 212.7 6 13.2 mg/dL,
1000 mg omega-3 fatty acids from flaxseed oil plus p , 0.001), serum insulin levels (15.0 6 11.6 vs
400 IU vitamin E supplements (n 5 30) or placebo 20.9 6 10.0 µIU/mL, p 5 0.02), and HOMA-IR
(n 5 30) for 6 weeks. Fasting blood samples were (11.2 6 2.7 vs 20.8 6 2.2, p 5 0.002) and decreased quan-
obtained at the beginning of the study and after 6-week titative insulin sensitivity check index (20.007 6 0.02 vs
intervention. Changes in fasting plasma glucose 10.01 6 0.03, p50.004). Administration of the control diet
(211.8 6 11.0 vs 11.5 6 11.9 mg/dL, p , 0.001), serum resulted in a significant difference in serum triglyceride
insulin concentrations, HOMA-IR, HOMA of beta-cell changes (131.3 6 38.0 vs 18.9 6 46.1 mg/dL, p 5 0.03)
function, and quantitative insulin sensitivity check index compared with soy protein. There were significant
decreases in total antioxidant capacity (235.0 6 136.2 fiber or LGL diet without fiber. It was found that 7
vs 181.8 6 188.8 mmol/L, p 5 0.005) and glutathione (38.9%) of 18 women with GDM in the fiber group and
(241.3 6 145.7 vs 153.3 6 117.3 µmol/L, p50.004) by the 10 (76.9%) in the without fiber group required insulin
control diet intake compared with soy protein. The control treatment, thus demonstrating that an LGL diet with
diet group had a higher incidence of newborn hyperbilirubi- added fiber for women with GDM dramatically reduced
nemia (32.4% vs 8.8%, p50.01) and newborn hospitaliza- the need for insulin treatment [46].
tion (20.6% vs 2.9%, p50.02) compared with soy protein. The effect of an LGI versus a conventional high-fiber
Soy protein consumption in women with GDM significantly diet on pregnancy maternal metabolic profile in GDM
improved the glucose homeostasis parameters, triglycerides, was examined. A total of 99 women (age 26 42 years;
and biomarkers of oxidative stress, as well as reductions in mean 6 SD prepregnancy BMI 24 6 5 kg/m2 ) diagnosed
the incidence of newborn hyperbilirubinemia and hospitali- with GDM at 20 32 weeks’ gestation were randomized
zations [41]. to follow either an LGI (n550; target GI B50) or a high-
fiber moderate-GI diet (HF) (n 5 49; target GI B60). LGI
group achieved a modestly lower GI than the HF group
D Dietary Patterns (mean 6 SEM 47 6 1 vs 53 6 1; p , 0.001). At birth, there
were no significant differences in birth weight (LGI
1 Low Glycemic Index Diet 3.3 6 0.1 kg vs HF 3.3 6 0.1 kg; p 5 0.619), birth weight
In controlling diabetes, it is generally recommended to centile (LGI 52.5 6 4.3 vs HF 52.2 6 4.0; p 5 0.969), prev-
limit the intake of high glycemic index (GI) foods (highly alence of macrosomia (LGI 2.1% vs HF 6.7%; p 5 0.157),
processed breakfast cereals, instant potatoes, instant noo- insulin treatment (LGI 53% vs HF 65%; p 5 0.251), or
dles, sugar, honey, molasses, corn syrup, candy, sweet- adverse pregnancy outcomes. In this study, an LGI diet
ened beverages, and fruit, fruit juice, and milk). A diet and a conventional HF diet produced similar pregnancy
consisting of low glycemic index (LGI) foods (e.g., whole outcomes [47].
wheat bread, old-fashioned oatmeal, bran cereal, nuts, A randomized study compared the effects of a conven-
legumes, and lentils) may offer a viable alternative to the tional diet (40% carbohydrate/45% fat/15% protein) to
traditional lower carbohydrate meal plan [42]. one consisting of a higher-complex carbohydrate (HCC)
An LGI diet in pregnancy was found to have a benefi- and low fat (LF) (60/25/15%) Choosing Healthy Options
cial effect on neonatal central adiposity and also on post- In Carbohydrate Energy (CHOICE) diet in 16 women
prandial glucose [43]. Grant et al. studied the effect of an with GDM. There were no between-diet differences for
LGI diet on blood glucose in women with GDM. Non- fasting or mean nocturnal glucose, but 24-hour area under
Caucasian women were randomized to an LGI (n 5 23) or the curve (AUC) was slightly higher (B6%) on the HCC/
control (n524) diet and followed from 28 weeks gesta- LF CHOICE diet (p 5 0.02). The continuous glucose
tion until delivery. Glycemic control improved on both monitoring system (CGMS) revealed modestly higher 1-
diets; however, more postprandial glucose values were and 2-hour postprandial glucose on CHOICE (1 hour,
within target on LGI (58.4% of n51891) compared to 115 6 2 vs 107 6 3 mg/dL, p # 0.01; 2 hour, 106 6 3 vs
control (48.7% of n51834; p , 0.001). SMBG postbreak- 97 6 3 mg/dL, p50.001) but well below current targets.
fast was directly related to the prepregnancy BMI at base- After breakfast, 5-hour glucose and insulin AUCs were
line. The authors concluded that an LGI diet was slightly higher (p , 0.05), triglycerides AUC was no dif-
acceptable in this sample and enabled control of post- ferent, but the free fatty acids (FFAs) AUC was signifi-
prandial glucose [44]. cantly lower (B19%; p # 0.01) on the CHOICE diet.
In another randomized study, 63 women with GDM This highly controlled study randomizing isocaloric diets
were assigned to receive either an LGI diet or a conven- and using a CGMS was the first to demonstrate that liber-
tional high-fiber (and higher GI) diet. Of the 31 women alizing complex carbohydrates and reducing fat still
randomly assigned to an LGI diet, 9 (29%) required insu- achieved glycemia below current treatment targets and
lin. Of the women randomly assigned to a higher GI diet, lower postprandial FFAs. The authors concluded that this
a significantly higher proportion, 19 of 32 (59%), required diet strategy may have important implications for prevent-
insulin treatment (p 5 0.023). However, 9 of these 19 ing macrosomia [48]. Additional maternal and infant
women were able to avoid insulin use by changing to an parameters were measured in 12 of the 16 participating
LGI diet, thus demonstrating that the use of insulin was women. After approximately 7 weeks, fasting blood
reduced in almost half [45]. A similar study examined the glucose (p 5 0.03) and FFAs (p 5 0.06) decreased on the
effect of low glycemic load (LGL) diet with (additional CHOICE diet, whereas fasting glucose increased on
15 g of wheat fiber) and without fiber in women with the conventional diet (p 5 0.03). Insulin suppression of
GDM requiring insulin. A total of 31 GDM women were adipose tissue lipolysis was improved on CHOICE versus
randomly assigned to consume either an LGL diet with conventional diet (56% vs 31%, p 5 0.005), consistent
with improved insulin resistance. Adipose tissue expres- influenced systolic blood pressure. Mean changes of fast-
sion of multiple proinflammatory genes was lower on the ing plasma glucose were not significant when comparing
CHOICE diet (p , 0.01). Infant adiposity was lower with the DASH diet with the control diet [52].
CHOICE versus conventional diet (10.1 6 1.4% vs Overall, the benefits of the DASH diet in GDM when
12.6 6 2%) [49]. followed for a 4-week period resulted in improved infant
Overall, a diet higher in complex carbohydrate and (lower birth weight, head circumference, and ponderal
fiber and low in simple sugars and fat may be effective in index) and maternal (reduced insulin, hemoglobin A1C,
preventing postprandial hyperglycemia, reduce FFAs, total cholesterol, LDL-cholesterol, oxidative stress, and
improve insulin resistance, and reduce the need for insulin systolic blood pressure) outcomes.
during GDM. In addition, reduced neonatal central adi-
posity and overall reduced fetal adiposity were observed
when using these diets.
E Nutrition Management Summary
MNT remains the cornerstone of treatment for GDM and
is best prescribed by a registered dietitian or a qualified
2 DASH Diet individual with experience in the management of GDM.
In a randomized trial of 52 women with GDM, the study Nutrition recommendations for GDM, including gesta-
participants were assigned to consume either a control tional weight gain, calorie intake, and macronutrient com-
(n526) or a Dietary Approaches to Stop Hypertension position and distribution, are based on limited scientific
(DASH) diet (n526) for 4 weeks. The control diet con- evidence [53]. Current nutrition practice guidelines for
tained 45 55% carbohydrates, 15 20% protein, and GDM recommend a carbohydrate-controlled meal plan
25 30% total fat. The DASH diet was rich in fruits, with adequate nutrient content aimed to support maternal
vegetables, whole grains, and low-fat dairy products and needs and fetal growth [54]. In addition to practice guide-
contained lower amounts of saturated fats, cholesterol, lines, research findings associating macronutrients and
and refined grains with a total of 2400 mg/day sodium. caloric prescriptions to maternal and birth outcomes are
The need for insulin in the DASH diet group was signifi- also available [29]. Using the current nutrition practice
cantly lower than for women in the control group (23% guidelines in combination with new research findings can
for DASH vs 73% for control group, p , 0.0001). help the registered dietitian individualize a meal plan that
Compared to infants in the control diet, those born to will contribute to the delivery of a healthy infant.
mothers following the DASH diet had significantly lower
weight (3222.7 vs 3818.8 g, p , 0.0001), head circumfer-
ence (34.2 vs 35.1 cm, p50.01), and ponderal index (2.50
IX PHYSICAL ACTIVITY
vs 2.87 kg/m3, p , 0.0001) [50]. In a randomized con- Moderate exercise may be an important adjunctive ther-
trolled study of women with GDM, the effects of the apy in the management of diabetes in pregnancy, particu-
DASH diet on insulin resistance, serum hs-CRP, and bio- larly in GDM. The benefits of regular physical activity
markers of oxidative stress among pregnant women with are found in Table 32.7. ACOG recommends that unless
GDM were studied. The control diet contained 40 55% contraindicated, pregnant women should participate in at
of its energy as carbohydrates, 10 20% as proteins, and least 20 30 minutes of moderate-intensity physical activ-
25 30% as total fats. Consumption of the DASH diet ity on most or all days of the week [55]. Physical activity
compared with the control diet resulted in decreased FPG should include aerobic and strength conditioning exercises
(27.62 vs 3.68 mg/dL; p50.02), serum insulin levels individualized by the health care provider. A list of exer-
(22.62 vs 4.32 µIU/mL, p50.03), and HOMA-IR score cises deemed safe and unsafe during pregnancy is found
(20.8 vs 1.1; p50.03). Increased concentrations of in Table 32.8. Women with GDM and taking insulin
plasma total antioxidant capacity (45.2 vs 2159.2 mmol/
L; p , 0.0001) and total glutathione levels (108.1 vs
2150.9 µmol/L; p , 0.0001) also were seen in the DASH TABLE 32.7 Physical Activity Benefits in GDM
group compared to the control group [51]. A similar study G Decreased physical discomforts associated with pregnancy
that compared adherence to the DASH dietary pattern to a G Shorter active phase of labor
control diet in women with GDM resulted in improved G Improved sleep
glucose tolerance after the glucose load. Decreased A1C G Decreased stress and anxiety
levels were also seen in the DASH group compared with G Increased insulin sensitivity
G Improved glycemic control
the control group. Mean changes for serum total and G May help to avoid excessive weight gain
LDL-cholesterol, and total HDL-cholesterol ratio were G k physical discomforts
significantly different between the two diets.
Additionally, consumption of the DASH diet favorably
or an oral hypoglycemic agent may need to have X PHARMACOLOGICAL THERAPY

carbohydrate-type snacks close at hand should they expe-
rience hypoglycemia. To prevent hypoglycemia, exercise Pharmacological therapy is prescribed when MNT, physi-
should be avoided in the fasting state and during periods cal activity, and lifestyle intervention in a woman with
of peak insulin activity. Blood glucose levels should be GDM cannot achieve or maintain target blood glucose
monitored before and after exercise. levels and/or when the rate of fetal growth is higher than
normal [54]. However, there is no conclusive evidence to
recommend an optimal time to begin pharmacotherapy.
Studies have suggested 1 2 weeks after the initiation of
TABLE 32.8 Physical Activities Considered Safe and
MNT and the glycemic levels remain elevated [54,56].
Unsafe During Pregnancy
Safe Activities A Insulin Therapy
G Swimming For many years, insulin was the only medication approved
G Water aerobics
G Walking
for use to control blood glucose levels in pregnancy.
G Jogging Although several types of insulin are available today, not
G Low-impact aerobics all are used in pregnancy. Insulin is either identical to
G Prenatal yoga human insulin (regular, neutral protamin Hagedorn [NPH])
G Stationary bike or insulin analogs (aspart, lispro, glulisine, determir,
G Modified weight training
glargine, or degludec) and varies in onset, peak times, and
Unsafe Activities duration in the body (see Table 32.9). Until June 2015, all
G Horseback riding drugs used in pregnancy were categorized by the U.S.
G Contact sports (e.g., soccer, basketball, volleyball) Food and Drug Administration using the following letter-
G Downhill skiing ing system: A, B, C, D, and X. In its place, medications
G Gymnastics
are now based on an individualized risk assessment [57].
G Bike riding
G Scuba diving The amount of insulin is dependent on the woman’s
G Sauna, hot tubs, steam room body weight and trimester of pregnancy (Table 32.10). The
G Any activity that involves lying on the back total amount of insulin is based on the insulin to carbohy-
Source: From March of Dimes, http://www.marchofdimes.org/pregnancy/
drate (ICR) ratio. Rapid-acting analogs are preferred to reg-
exercise-during-pregnancy.aspx; ACOG Committee Opinion 650, ular insulin because their action begins 5 to 15 minutes and
Physical activity and exercise during pregnancy and the postpartum food is consumed immediately after the injection. The
period, 2015.
onset and peak times for regular women delays when the
TABLE 32.9 Insulin for Blood Glucose Management
Insulin Type Onset Peak Action Duration

Rapid-Acting
Lispro 0 15 min 30 90 min 3 6.5 h
Aspart 0 15 min 60 120 min 3 5h
Glulisine 0 15 min 60 120 min 3 4h
Short-Acting
Regular (Humulin, Novolin) 30 60 min 2 3h 3 6h
Intermediate-Acting
NPH 1.5 4 h 4 12 h 12 18 h
Long-Acting
Glargine 1 2h Flat 24 h
Detemir 0.8 2 h Peakless Up to 24 h
Source: From E.M. Sisson, D.L. Dixon, Pharmacotherapy for glucose management, in: C. Messing (Ed.), The Art and Science of Diabetes Self-Management
Education: A Desk Reference for Healthcare Professionals, third ed., American Association of Diabetes Educators, Chicago, IL, 2014.
XI DIABETES SELF-MANAGEMENT
TABLE 32.10 Insulin Requirements During Pregnancy EDUCATION AND BEHAVIORAL
Insulin Dose (Units/kg APPROACH
Actual Body Weight)
Diabetes self-management education (DSME) is a critical
First trimester 0.6 0.8 element of care for all people with diabetes and is neces-
Second trimester 0.7 1.0 sary in order to improve patient outcomes. The National
Third trimester 0.8 1.2
Standards for DSME are designed to define quality
DSME and to assist diabetes educators in a variety of set-
With obesity ( . 150% of 1.5 2.0, secondary to tings to provide evidence-based education. Because of the
desirable body weight) insulin resistance
dynamic nature of health care and diabetes-related
Source: From American College of Obstetricians and Gynecologists, research, these standards are reviewed and revised
Pregestational diabetes mellitus, Practice bulletin No. 60, Obstet. Gynecol.
105 (2005) 680; L. Shields, G.S. Tsay (Eds.), California Diabetes and
approximately every 5 years by key organizations and
Pregnancy Program Sweet Success Guidelines for Care. Developed with federal agencies within the diabetes education community
California Department of Public Health; Maternal Child and Adolescent
Health Division, revised edition, chapter updated September 2015.
[62]. The overall objectives of DSME are to support
informed decision-making, self-care behaviors, problem-
solving, and active collaboration with the health care
woman is able to eat. NPH is usually given in 2 doses: one team and to improve clinical outcomes, health status, and
at breakfast and the othe before bedtime. If using a long- quality of life. One of the guiding principles of DSME is
acting insulin, it is usually injected once daily during the behavioral goal setting as an effective strategy to support
evening meal or at bedtime. Adjustment is made to the self-management behaviors [62]. Diabetes self-
insulin dosage based on the glycemic levels. management support (DSMS) refers to the support that is
required for implementing and sustaining coping skills
and behaviors needed to self-manage on an ongoing basis.
B Oral Hypoglycemic Agents The initial DSME is typically provided by a health profes-
Since the landmark trial on the use of glyburide in the sional, whereas ongoing support can be provided by
management of GDM, the popularity of oral hypoglycemic personnel within a practice and a variety of community-
agents has increased. This randomized trial reported no dif- based resources. DSME/S programs are designed to
ference in the incidence of maternal or fetal complications address the patient’s health beliefs, cultural needs, current
between glyburide and insulin and no glyburide was knowledge, physical limitations, emotional concerns, fam-
detected in the cord serum [58]. Glyburide, a sulfonylurea, ily support, financial status, medical history, health liter-
releases insulin from the pancreas, thereby lowering blood acy, numeracy, and other factors that influence each
glucose levels. It is considered a viable alternative to insu- person’s ability to meet the challenges of self-
lin because of its ease of use and the cost benefit. management [63]. Successful diabetes care requires a sys-
However, later studies have shown that glyburide crosses tematic approach to supporting patients’ behavioral
the placenta and is associated with an increased risk of change including (a) healthy lifestyle changes (physical
neonatal intensive care admissions, respiratory distress syn- activity, healthy eating, nonuse of tobacco, weight man-
drome, neonatal hypoglycemia, birth injury, and large-for- agement, effective coping), (b) disease self-management
gestational age infants [59,60]. Glyburide is also associated (medication taking and management; self-monitoring of
with hypoglycemia in the mother. The maximum dosage of blood glucose and blood pressure when clinically
glyburide in pregnancy is 20 mg. Insulin is initiated if appropriate), and (c) prevention of diabetes complications
maternal glycemic levels remain above target after the (self-monitoring of foot health; active participation in
maximum dose has been reached. screening for eye, foot, and renal complications; immuni-
Metformin is a biguanide, an insulin sensitizer that zations). National DSME standards call for an integrated
acts by decreasing the hepatic production and intestinal approach that includes clinical content and skills, behav-
absorption of glucose. Although metformin was also ioral strategies (goal setting, problem-solving), and
shown to cross the placenta, it does not cause maternal addressing emotional concerns in each needed curriculum
hypoglycemia and may be a superior alternative to gly- content area [64].
buride [61]. Metformin is associated with mild weight A systematic review of controlled trials evaluated
loss and may slightly increase the risk of prematurity [4]. behavior modification interventions to prevent the devel-
The beginning dose of metformin is 500 mg one or two opment of GDM. Nine studies were identified involving
times daily, with a maximum dose in pregnancy of such techniques as repetition of information, use of verbal
2500 mg; there are currently no long-term studies on the and written educational information, goal setting, and
effect of oral hypoglycemic agents on the offspring. planning, in addition to group and individual counseling
TABLE 32.11 Specific, Measurable, Achievable, Relevant, and Time-Limited Goals in the Management of Diabetes
Type of Goals Example

Specific goal I will check my blood glucose
Specific, measurable goal I will check my blood glucose three times every day
Specific, measurable, achievable goal I will check my blood glucose before breakfast, after lunch, and before bed time
Specific, measurable, achievable, To avoid hypoglycemic episodes, I will check my blood glucose every day before breakfast,
relevant goal after lunch, and before bed time
Specific, measurable, achievable, Starting tomorrow and to avoid hypoglycemia episodes, I will check my blood glucose every
relevant, time-limited goal day before breakfast, after lunch, and before bed time
sessions. The combination of planning and goal setting to achieve goals is the use of S.M.A.R.T. (Specific,
was used successfully in improving the diets of women. Measurable, Achievable, Relevant, and Time-limited)
The findings of the review determined that the use of goals (Table 32.11).
self-monitoring, goal setting, and achievement appears to Specific. The goal should be clearly defined. Stating
be effective in the prevention of excessive gestational that people want to have a better glucose control is not
weight gain (EGWG), especially when combined with a specific enough. Focusing on one specific element such
high frequency of intervention contact, individual atten- as blood glucose control would make the goal specific.
tion, and professional involvement [65]. The effectiveness Measurable. Setting a measurable goal would make
of single versus multiple goal setting for diet and physical people accountable for an action that could result in dia-
activity was evaluated in a randomized controlled trial of betes control.
overweight or obese adults with T2DM and multiple Achievable. A realistic goal that allows
cardiovascular disease risk factors. At baseline, the accomplishment.
multiple-goal group self-selected both diet- and physical Relevant. Knowing that a better glucose control could
activity-related goals, the single-goal group set a single result in positive diabetes outcomes such as A1C within
goal, and the control group received information about com- target levels.
munity health resources. From pre- to postintervention, the Time-limited. A tangible and concrete goal would
single-goal group demonstrated significant improvement in allow people with diabetes to have a sense of
systolic blood pressure and intake of servings of fruits, accomplishment.
vegetables, and refined grains (all p , 0.05). The multiple- An example of a S.M.A.R.T. goal is: “I will eat a
goal group reported significant reduction in percent energy lunch containing 60 grams of carbohydrates every day
from total, saturated, monounsaturated, and trans-fat intake during the month” [68].
and significant increase in leisure time walking (all
p , 0.05). The authors concluded that a multiple-goal
approach over 4 months can improve dietary and physical
A Team-Based Approach
activity outcomes, while a single-goal approach may facili- According to ADA, persons with diabetes should receive
tate improvement in one behavioral domain [66]. medical care from a team that may include physicians,
Patients’ perception of collaborative goal setting was nurse practitioners, physician’s assistants, nurses, regis-
evaluated using a semistructured focus group guide. tered dietitians, pharmacists, and mental health profes-
Collaborative goal setting was described by patients as sionals with expertise in diabetes. It is essential in this
occurring within the context of a caring relationship collaborative and integrated team approach that indivi-
where patients and health care providers: (1) listen and duals with diabetes assume an active role in their care.
learn from each other; (2) share ideas; (3) agree on a mea- The management plan should be formulated as a collabo-
surable objective; and (4) support goal achievement. rative therapeutic alliance among the patient and family,
Patients also articulated clear responsibilities for them- the physician, and other members of the health care team.
selves and clinicians and described collaborative goal set- A variety of strategies and techniques should be used to
ting as a process that occurs over time [67]. Therefore, provide adequate education and development of problem-
goal setting and goal achievement are instrumental in the solving skills in the various aspects of diabetes manage-
management of diabetes and behavior modification. In ment. Implementation of the management plan requires
diabetes management a technique that has been proposed the goals and treatment plan to be individualized and to
take patient preferences into account. The management In conjunction with the patient and family members,
plan should recognize DSME and ongoing diabetes sup- health professionals from different disciplines and com-
port as an integral component of care. In developing the munity providers compose the team. The five personal
plan, consideration should be given to the patient’s age, values that characterize the most effective members of
school or work schedule and conditions, physical activity, high-functioning teams in health care are: honesty, disci-
eating patterns, social situation and cultural factors, and pline, creativity, humility, and curiosity. The principles
the presence of diabetes and other medical complications that support high-quality team-based care include shared
[69]. goals, clear roles, mutual trust, effective communication,
The Chronic Care Model (CCM), an organizational and measurable processes and outcomes. These principles
approach to caring for people with chronic disease in a pri- are not intended to be in isolation but are interwoven and
mary care setting, has been shown to be an effective frame- each is dependent on the others. In addition, these teams
work for improving the quality of diabetes care [70]. require sufficient organizational resources to sustain their
Collaborative, multidisciplinary teams are best equipped to work [72]. Developing a clear understanding of and
provide care for people with chronic conditions such as respect for specific roles and responsibilities can be maxi-
diabetes. The key objectives of the CCM are to: mized to support achievement of the team’s shared goals.
The organizational factors that enable establishing and
1. Optimize provider and team behavior. The care team
maintaining clear roles include:
should prioritize timely and appropriate intensification
of lifestyle and/or pharmacological therapy for Providing time, space, and support for interprofes-
patients who have not achieved beneficial levels of sional education and training, including explicit
glucose, blood pressure, or lipid control. opportunities to practice the skills and refine the
2. Support patient behavior change. High-quality DSME values that support teamwork.
has been shown to improve patient self-management, Facilitating communication among team members
satisfaction, and glucose control. regarding their roles and responsibilities.
3. Change the care system. Optimal diabetes manage- Redesigning care processes and reimbursement to
ment requires an organized, systematic approach and reflect individual and team capacities for the safe and
involves a coordinated team of dedicated health care effective provision of patient care needs.
professionals.
A number of strategies and practices provide the frame-
In addition, a patient-centered communication style work for an effective team-based approach. An example of
should be used that incorporates patient preferences, a team-based plan of work is shown in Table 32.12.
assesses literacy and numeracy, and addresses cultural A study by Baker et al. found evidence that team
barriers to care [71]. training improves patient safety. Three competencies criti-
A high-performing team is now widely recognized as cal for effective team work include:
an essential tool for constructing a more patient-centered,
coordinated, and effective health care delivery system. 1. Teamwork-related knowledge: understanding the skills
Team-based health care is the provision of health services and behaviors needed for an effective team and how
to individuals, families, and/or their communities by at they are manifested in a team setting.
least two health providers who work collaboratively with 2. Teamwork-related skills: the learned capacity to inter-
patients and their caregivers—to the extent preferred by act with other team members.
each patient—to accomplish shared goals within and 3. Teamwork-related attitudes: internal states that influ-
across settings to achieve coordinated, high-quality care. ence a team member.
TABLE 32.12 Team-Based Plan to Prevent T2DM After GDM
T2DM Prevention After GDM

Team Composition: Patient, family members, physicians, nurse practitioners, physician’s assistants, nurses, registered dietitians,
pharmacists, and mental health professionals and support personnel with expertise in diabetes.
Clinical Care: The goal of the multidisciplinary team is to support and treat women with a history of GDM to avoid or delay the onset of
T2DM. Women will require an OGTT at 8 12 weeks postpartum.
Team Process: Clinicians collaboratively develop and implement a treatment plan. The team agrees on and implements reliable and
timely feedback on successes and failures and on the achievements of the team’s goals. These are used to track and improve
performance. The team agrees on communication strategies and on a continuous improvement quality plan.
Areas that support effective team-based care are inter- thoughts about diabetes. By applying the cultural compe-
professional education and workforce development, health tence constructs, health care professionals may be better
informatics, and care coordination [73]. prepared to interact with a diverse population requiring
diabetes care and education [78].
According to the American Association of Diabetes
Educators’ position statement on cultural sensitivity, dia-
B Cultural Aspects betes educators are encouraged to develop a basic under-
Diabetes management requires individualized, patient- standing of key terminology, such as cultural sensitivity,
centered, and culturally appropriate strategies. Cultural cultural humility, cultural competence, multicultural, cul-
competency is critical to reducing health disparities and tural tailoring, racial identity, and ethnic identity [79].
improving access to high-quality health care that is Summary recommendations for diabetes education on
respectful of and responsive to the needs of diverse cultural competency in support of persons affected by dia-
patients [74]. According to the U.S. Census Bureau, betes include [80]:
ethnic and minority groups accounted for more than G Acknowledges that cultural perceptions of health can
one-third of the population in 2012, with projections indi-
be unique for each individual.
cating that the United States will become a majority- G Considers the context of learning experiences already
minority nation for the first time in 2044. The minority
present when developing collaborative efforts with the
population is projected to rise to 56% of the total in 2060,
patient to identify barriers to diabetes care success.
compared with 38% in 2014 [75]. Ethnic groups at high G Conveys accurate information that is understandable
risk for developing GDM include Hispanic, African-
to the learner.
Americans, Native American, South East Asian, Pacific G Proactively addresses limitations to self-management
Islander, or Indigenous Australian groups. Women with
plan adherence and designs/brokers culturally appro-
GDM who are of Hispanic or African-American back-
priate goals.
grounds are more likely to develop hypertension postpar- G Utilizes educational materials and resources appropri-
tum. A literature review highlights the fact that diabetes
ate for culture, age, literacy level, and learning
management must be individualized and the clinician
readiness.
should be mindful of the impact differences in ethnicity G Includes resources that address access limitations to
may have on the clinical characteristics and pregnancy
diabetes care needs and considers the milieu in which
outcomes in women affected by GDM, particularly those
the care plan is to be executed.
living in Western countries. MNT plays a key role in the G Incorporates sensitivity and respect when educating all
management of GDM and the nutrition prescription
people irrespective of ethnicity, race, age, and socio-
should be culturally sensitive. Understanding these differ-
economic status.
ences is critical in the delivery of optimal antenatal care
for women from diverse ethnic backgrounds [76].
Cultural competency plays an important role in the
communication and counseling carried out by food and XII POSTPARTUM
nutrition practitioners [77]. To understand the connections
A Breast-feeding
between cultural food practices and diabetes among ethnic
and racial groups, cultural competence must be gained Research continues to support the positive effects of
first. Culture influences values, beliefs, and practices breast-feeding (BF) on maternal and infant health, as
related to food and diabetes. Differences between racial human milk contains the proper balance of nutrients and
and ethnic groups provide a context for examining cul- immunologic agents that closely match infant growth
tural food practices and their impact on diabetes manage- requirements. It is the position of the Academy of
ment. To best serve the health care needs of racial and Nutrition and Dietetics that exclusive BF provides optimal
ethnic groups with diabetes, health care professionals nutrition and health protection for the first 6 months of
must acknowledge each group’s attitudes, beliefs, and life, and BF with complementary foods from 6 months
values, including specific knowledge about food habits, until at least 12 months of age is the ideal feeding pattern
preferences, and practices (e.g., holidays, celebrations, for infants. The position recommends BF regardless of
and fasting practices). Cultural competence constructs the presence of GDM [81].
include understanding the language, thoughts, communi- Recent studies have documented the association of
cations, actions, customs, beliefs, values, and institutions GDM and BF on maternal biomarkers for T2DM and on
of ethnic, racial, religious, or social groups. Recognizing childhood overweight. The Study of Women, Infant
these cultural constructs may better prepare health care Feeding, and Type 2 Diabetes (SWIFT) investigated
professionals to understand their clients’ feelings and whether higher lactation intensity is related to more
favorable blood lipids, lipoproteins, and adipokines (adipo- B Prevention of Gestational Diabetes
nectin, leptin) after a GDM pregnancy independent of obe-
sity, sociodemographics, and insulin resistance. A sample Evidence on the association between dietary patterns and
of 1007 women of diverse ethnic backgrounds with previ- the risk of GDM has been extensively documented. In the
ous GDM were divided into exclusive and mostly BF or Nurses’ Health Study II, the Western diet (characterized
exclusive or mostly formula feeding (FF) groups, with bio- by a high intake of red meat, processed meat, refined grain
markers being measured after 6 9 weeks postpartum. products, sweets, French fries, and pizza) was found to
Compared to FF groups, BF group reported 5 8% higher increase the risk for developing GDM. Pregravid intake of
HDL cholesterol, 20 28% lower fasting triglycerides, red and processed meats was significantly and positively
15 21% lower leptin (all trend p-values ,0.01), and 6% associated with GDM risk, independent of known risk fac-
lower adiponectin, but only after adjustment for insulin tors for T2DM and GDM. After the adjustment for major
resistance (trend p-value50.04). Findings suggest that lac- risk factors for GDM, those who consumed more than six
tation has favorable short-term influences on biomarkers servings of red meat in a week had more than a 1.7-fold
for T2DM, except for plasma adiponectin [82]. increased risk of GDM compared with those women who
Furthermore, the long-term effects of lactation and the inci- consumed less than 1.5 servings of red meat/week (relative
dence of T2DM after a GDM pregnancy were evaluated in risk: 1.74; 95% CI: 1.35, 2.26). In addition, compared to
a subsample of 959 women from the SWIFT study wherein women who consumed one serving per month, those who
113 (11.8%) developed incident T2DM. It was found that consumed more than five servings per week of sugar-
higher lactation intensity and longer duration were inde- sweetened cola had a 22% greater GDM risk (relative risk:
pendently associated with lower 2-year incidences of 1.22; 95% CI: 1.01, 1.47) [86]. Similarly, the consumption
T2DM after GDM pregnancy, thus concluding that lacta- of fried foods was associated with the risk of GDM. After
tion may prevent T2DM after GDM delivery [83]. adjustment for age, parity, dietary, and nondietary factors,
The association of GDM and BF on childhood over- the relative risks (95% CIs) of GDM among women who
weight has been evaluated. One study of 15,710 consumed fried foods 1 3, 4 6, and $ 7 times/week,
mother offspring pairs delivered in 2011 assessed the compared with those who consumed them less than once/
relationship among maternal obesity, EGWG, GDM, and week, were 1.13 (0.97, 1.32), 1.31 (1.08, 1.59), and 2.18
BF with respect to childhood obesity (BMI .85th percen- (1.53, 3.09), respectively (p ,0.001). The association per-
tile) at age 2 years. Logistic regression was used to assess sisted after further adjustment for BMI (p50.01) [87].
associations between maternal exposures and childhood Dietary patterns found to reduce the risk for develop-
overweight. Analysis adjusted for exposures and covari- ing GDM include the prudent diet (characterized by a
ates revealed an adjusted odds ratio (95% confidence high intake of fruit, green leafy vegetables, poultry, and
interval [CI]) associated with childhood overweight at age fish) [86], Mediterranean patterns (high intake of fruit,
2 years of 2.34 (2.09 2.62), 1.50 (1.34 1.68), 1.23 vegetables, legumes, fish, and whole grains), and the
(1.12 1.35), 0.95 (0.83 1.10), and 0.76 (0.69 0.83) for DASH diet [88 90]. Overall, dietary patterns rich in fruit,
maternal obesity, overweight, EGWG, GDM, and BF $ vegetables, whole grains, and fish and low in red and pro-
6 months versus ,6 months, respectively. The study con- cessed meat, refined grains, and high-fat dairy were found
cluded that GDM and BF $ 6 months were not associ- to be beneficial in the prevention of GDM [91,92].
ated with childhood overweight at age 2 years. However,
maternal prepregnancy obesity or overweight and EGWG C Prevention of Type 2 Diabetes Mellitus
were independently associated with an increased risk of
childhood overweight and BF $ 6 months with a
(T2DM)
decreased risk of childhood overweight at age 2 years Women with a history of GDM are at risk for developing
[84]. Another study examined the association of GDM T2DM within 5 10 years after delivery [93]. The ADA—
and BF on obesity prevalence in predominately Hispanic 2016 Standards of Medical Care in Diabetes recommends
low-income children (2 4 years). Data from 2295 chil- screening women with GDM for persistent diabetes at
dren (84% Hispanic and 48% female) were obtained from 6 12 weeks postpartum using the OGTT and clinically
caregivers participating in the Special Supplemental Food appropriate nonpregnancy diagnostic criteria (Table 32.13)
Program Women, Infant, and Children. Chi-square and [1]. However, less than half of women who had GDM
binary logistic regression were used to assess GDM and return for diabetes testing [94].
BF duration with the children’s ethnicity, birth weight, Healthy Babies Need Healthy Moms (HBNHM) is an
age in months, and sex as prior covariates. The results education program that combines the recommended
showed that GDM offspring who were breastfed $ 12 2-hour postpartum OGTT with diabetes prevention educa-
months had a 72% decrease in obesity prevalence tion for women who had GDM. The 2-hour OGTT is
(adjusted odds ratio 5 0.28, CI 0.89 0.03, p 5 0.05) [85]. performed during the class and in between venipunctures,
TABLE 32.13 Criteria for Diagnosis of Diabetes Mellitus Using a 75 g OGTT
Normal Values, Prediabetes Diabetes Mellitus,

mg/dL (mmol/L) mg/dL (mmol/L)
Fasting plasma glucose ,100 mg/dL $100 , 126 mg/dL $126 mg/dL
(5.6 mmol/L) ($5.6 7.8 mmol/L) ($7.0 mmol/L)
75 g OGTT ,140 mg/dL ,140 mg/dL $200 mg/dL
(7.8 mmol/L) (7.8 mmol/L) (11.8 mmol/L)
Source: From American Diabetes Association, Standards of Medical Care. Classification and diagnosis of diabetes, Diabetes Care 39 (Suppl. 1) (2016)
S13 S22.
the women participate in group education focused on protein and fat intake from plant-based foods was not sig-
evidence-based diabetes prevention strategies that pro- nificantly associated with a risk of T2DM [97].
mote lifestyle behavior, the importance of preconception The Diabetes Prevention Program (DPP) was a major
care for subsequent pregnancies, and the need for follow- multicenter clinical research study aimed at discovering
up care for women who screen positive for abnormal whether modest weight loss through dietary changes and
glucose levels. For women who screen positive for overt increased physical activity or treatment with the oral dia-
diabetes or prediabetes, the educational strategies are betes drug metformin could prevent or delay the onset of
directed toward encouraging follow-up care. For women T2DM in study participants [98]. The DPP lifestyle inter-
with normal screening results, the program is designed to vention has been translated to community settings using
help prevent the future development of T2DM. Topics the DPP goals of reducing body weight by 7% and engag-
covered in the curriculum include pathophysiology of ing in moderate physical activity of 150 minutes per week.
T2DM; diabetes prevention and exercise; BMI, weight The CDC’s National Diabetes Prevention Program is an
loss, and nutrition; preconception counseling and tobacco evidence-based behavioral change program, designed to
screening. The nutrition goals of the program are to support lifestyle balance, healthy eating, physical activity,
reduce fat intake to ,30% of total energy intake, reduce and motivational support. The program is delivered by a
saturated fat intake to ,10%, and increase fiber intake to lifestyle coach, who facilitates the CDC-approved curric-
15 g/1000 kilocalories [95]. ula and works to encourage and sustain group interaction
Several healthful dietary patterns, including the alter- so that participants support each other during the year-long
nate Mediterranean Diet (aMED), DASH, and alternate program. It includes a handy preparation checklist with
Healthy Eating Index (aHEI), have been inversely associ- materials needed and tasks that are performed to do before
ated with T2DM risk and other cardiovascular disease in participants arrive, as they arrive, and after each session.
the general population but rarely investigated among For each session a lifestyle coach briefly outlines the
women with a history of GDM (Table 32.14). Validated objectives and key messages. Step-by-step instructions
food-frequency questionnaires were used to measure make it easy for lifestyle coaches to facilitate discussions
adherence to a healthful diet of 4413 women from the and activities. The curriculum also offers tips on tailoring
Nurses’ Health Study II cohort with histories of GDM. the sessions to meet participants’ needs and preferences,
Results of the study showed that the Mediterranean pat- including cultural considerations. The CDC-developed
tern was associated with 40% lower risk of T2DM (haz- curriculum is available in English and Spanish [99].
ard ratio, 0.60 [95% CI, 0.44 0.82; p 5 0.002]); the As part of the DPP, two studies assessed the effects of
DASH pattern, with 46% lower risk (0.54 [0.39 0.73; metformin on T2DM prevention in women with a history
p 5 0.001]); and the aHEI pattern, with 57% lower risk of GDM. In the study by Ratner et al., 2190 women were
(0.43 [0.31 0.59; p 5 0.001]). Adherence to healthful randomized to either standard lifestyle and placebo, metfor-
dietary patterns is associated with lower T2DM risk min therapy or to an intensive lifestyle intervention. The
among women with a history of GDM [96]. In a study by outcome was the time to development of diabetes ascer-
Bao et al., the effect of low-carbohydrate dietary pattern tained by semiannual fasting plasma glucose and annual
in women with prior GDM with respect to T2DM risk OGTT. Results of the study indicated that women with a
found that a low-carbohydrate dietary pattern, particularly history of GDM randomized to placebo had a crude inci-
with high protein and fat intake primarily from animal- dence rate of diabetes 71% higher than that of women
source foods, was associated with a higher T2DM risk, without such histories. Among women reporting a history
whereas a low-carbohydrate dietary pattern with high of GDM, both intensive lifestyle and metformin therapy
TABLE 32.14 Dietary Patterns and Risk for Developing GDM and T2DM After GDM
Stage Risk Dietary Pattern Foods Relative Risk (95% CI)

Risk for GDM High Western diet Overall diet: high intake of red meat, RR: 1.63 (1.20, 2.21); p 5 0.001
Prepregnancy processed, refined grain products, sweets, [88]
French fries, and pizza
RR: 1.74 (1.35, 2.26) [86]
RR:1.22 (1.01, 1.47) [86]
Red meat RR: 1.13 (0.97, 1.32) [87]
Sugar-sweetened cola RR: 1.31 (1.08, 1.59)
Fried foods RR: 2.18 (1.53, 3.09); p trend
,0.001
Low Mediterranean diet Plant-based foods (fruits, vegetables, RR: 0.76 (0.60, 0.95); p
whole grains, legumes, and nuts), fish and trend 5 0.004 [90]
seafood, olive and canola oil and reduced
intake of red and processed meats
Dietary Approaches Plant-based foods (fruits, vegetables, RR: 0.66 (0.53, 0.82); p
to Stop Hypertension whole grains, legumes, whole grains), trend 5 0.0005 [90]
(DASH) diet low-fat dairy, and reduced intake of
sweetened beverages and sodium
Healthy Eating Index Plant-based foods (fruits, vegetables, RR: 0.54 (0.43, 0.68); p
diet whole grains, legumes, nuts, whole grains, trend 5 0.0001 [90]
cereal fiber), higher ratio of white:red
meat, PUFA:SFA, multivitamin use, and
reduced trans fats
Risk for GDM Low Healthful diet and Vegetables, fruits and berries, whole-grain RR: 0.64 (0.38, 1.09) [92]
During 150 min/week products, rich in fiber, low-fat dairy
pregnancy moderate to intense products, vegetable fats high in
physical activity unsaturated fatty acids, fish, and low-fat
meat products, and a lower intake of
sugar-rich foods
Risk for type 2 High Low-carbohydrate Overall diet HR: 1.36 (1.04, 1.78); p
DM postpartum diet trend 5 0.003 [97]
with high protein and fat intake from HR: 1.40 (1.06, 1.84); p
animal-source food trend 5 0.004
with high protein and fat intake from HR: 1.19 (0.91, 1.55); p
plant-source food trend 5 0.50
Low Mediterranean diet RR: 0.60 (0.44, 0.82); p 5 0.002
[90]
DASH diet RR: 0.54 (0.39,0.73); p 5 0.001
Healthy Eating Index RR: 0.43 (0.31, 0.59); p 5 0.001
diet
RR, relative risk; HR, hazard ratio.

Source: From C. Zhang, M.B. Schulze, C.G. Solomon, F.B. Hu, A prospective study of dietary patterns, meat intake and the risk of gestational diabetes
mellitus, Diabetologia 49 (2006) 2604 2613.
reduced the incidence of diabetes by approximately 50% those without GDM [100]. In another similar study, 350
compared with the placebo group, whereas this reduction women with a history of GDM and 1416 women with pre-
was 49% and 14%, respectively, in parous women without vious live births but no history of GDM were assigned to
GDM. These data suggest that metformin may be more either placebo, intensive lifestyle intervention (ILS), or
effective in women with GDM histories as compared with metformin. In women with a history of GDM, ILS and
metformin reduced the progression to diabetes compared [10] A. Ferrera, Increasing prevalence of gestational diabetes mellitus:
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Chapter 32

Nutritional Management for Gestational

I INTRODUCTION dietitians, diabetes educators, nurses, social workers, and

Nutrition in the Prevention and Treatment of Disease. DOI: http://dx.doi.org/10.1016/B978-0-12-802928-2.00032-1

Source: From American Diabetes Association, Standards of Medical

test test glucose is established. The target blood glucose levels in

ing, and 1 and 2 h ing, and 1, 2, and 3 h

TABLE 32.3 Diagnostic Criteria for GDM for Various Organizations

TABLE 32.4 Institute of Medicine Weight Gain in Pregnancy Guidelines

TABLE 32.5 Prenatal Weight Gain Grid

TABLE 32.6 Target Plasma Glucose in Gestational Diabetes Pregnancy

Time American Diabetes Association and American CDAPP International Diabetes

CDAPP, California Diabetes and Pregnancy Sweet Success.

A Carbohydrates B Dietary Fat

or an oral hypoglycemic agent may need to have X PHARMACOLOGICAL THERAPY

TABLE 32.9 Insulin for Blood Glucose Management

Insulin Type Onset Peak Action Duration

Type of Goals Example

TABLE 32.12 Team-Based Plan to Prevent T2DM After GDM

T2DM Prevention After GDM

TABLE 32.13 Criteria for Diagnosis of Diabetes Mellitus Using a 75 g OGTT

Normal Values, Prediabetes Diabetes Mellitus,

Stage Risk Dietary Pattern Foods Relative Risk (95% CI)

RR, relative risk; HR, hazard ratio.

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